ANSWERS
_____ _____ involve some degree of self deception correct answer defense
mechanisms
_____ precautions are used in the care of all clients. correct answer Standard
_______ disconnect the IV tubing to remove a patients gown. Do not remove the
IV bag from the IV pump as a student nurse. Another nurse or your clinical
instructor must remove the IV bag from the pump for a gown change. correct
answer NEVER
-mycin correct answer antibiotics
30-35% of pt who fall sustain _____ correct answer injuries
A _____ room is recommended for any client with an infection correct answer
private
A 42-year-old man fell and twisted his left ankle while running earlier this
morning. Upon arrival to the ER, which of the following interventions would the
nurse choose for this patient? correct answer cold application
A 70 yo pt who suffers from worsening dementia is no longer able to live alone.
The nurse is discussing health care services and possible long-term living
arrangements with the patients only son. What will the nurse suggest? correct
answer a nursing center because home care is no longer safe
,A client admitted in a state of extreme anxiety has vital signs of T: 98.6G, P 81, BP
130/86, R 32. What will the nurse expect the result to be if this hyperventilation
continues? correct answer respiratory alkalosis
A client has been admitted to the hospital with advanced colon cancer and is
receiving palliative care at this time. The nurse feels anxious in caring for this
patient, but realizes which of the following? correct answer the pt needs the
nurses presence and personal connection
A client has been placed on palliative care. Which procedure does the nurse
recognize as inappropriate for this situation? correct answer knee replacement
surgery
A client has been suffering from liver cancer for more than a year. The family has
requested hospice services. The family members are taking turns staying with
their family member. They have been reminiscing with the client about her life
and are now saying their goodbyes. The type of grief that this family is
experiencing is best described as which of the following? correct answer
anticipatory
A client has consumed three 100 ml cups ice and 4oz ginger ale. What will the
UAP document as the clients oral intake? correct answer 3(100)= 300/2= 150
4(30)= 120
150+120= 270mL
A client suffering from lung cancer experiences nausea and vomiting. When
rendering palliative care, the nurse recognizes that this requires what type of
care? correct answer requires an interdisciplinary team
,A client tells a nurse, "My new friend is the most perfect person one could
imagine: kind, considerate, and good looking. I can't find a single flaw." Which
defense mechanism is the client demonstrating? correct answer idealization
A client tends to use the defense mechanism of displacement. When the clients
spouse accuses the client of being disorganized and flighty, which defense
mechanism is the client most likely to react by? correct answer scolding the
paperboy for being late
A client undergoing diagnostic test says, "Nothing is wrong with me except a
stubborn chest cold." The spouse reports the client smokes, coughs daily, lost
15lbs, and is easily fatigued. Which defense mechanism does the nurse recognize
the client using? correct answer denial
A client was admitted to your unit for dehydration. Which assessment would the
nurse identify as a possible sign of flood imbalance? correct answer reduced skin
turgor
A common side effect experienced by pt using bronchodilators is what? correct
answer nervousness
A cruel and abusive person often uses rationalization to explain the behavior.
Which comment demonstrates use of this defense mechanism? correct answer
that person should not have provoked me
A daughter is concerned about the age-related changes of her mother, who is 80
years old. Which statement(s) made by the daughter would likely represent(s) a
, normal change of aging? correct answer "My mother seems to get cold very
easily."
"My mother complains of her mouth being dry all the time."
"Mother goes around the house turning on all the lights."
A female client who was savagely attacked by a bear has no memory of the event.
Which statement to the nurse best explains the clients inability to remember the
attack? correct answer The client is unconsciously using a defense mechanism to
protect against the repeated memory of the attack
A fever would indicate a correct answer systemic infection
A middle-aged client with a terminal disease is speaking harshly to the nurse
every time the call light is answered. The nurse identifies that this pt is
experiencing the second stage of Kubler-Ross stages of dying. What is the second
stage? correct answer anger
A nurse classifies a pressure ulcer according to the type of tissue in the wound
bed. What does it indicate if the wound bed has granulation in it? correct answer
movement toward healing
A nurse delegates measure of vital signs to a nursing assistant. What task cannot
be delegated to an UAP? correct answer comparison to a pt baseline vitals
A nurse has a client that experience evisceration of an abdominal wound. What is
the nurses first action? correct answer attempts to place the intestinal protrusion
back into the incision